Watch a video introduction to this publication by Anne Beal, M.D., senior program officer for the Quality of Care for Underserved Populations Program
You can also watch a Fund E-Forum, with slides and audio from a related presentation delivered at a roundtable event, "Cultural Competency: Understanding the Present and Setting Future Directions," held in New York City on April 7, 2006.
This report reviews key principles of quality (as it relates to the overall quality of the health care system and individual approaches to quality improvement); reviews evidence of the existence and root causes of racial and ethnic health disparities and recommendations to address them; and discusses strategies by which the quality and cultural competence movements could be linked. In particular, it focuses on the Institute of Medicine's six principles for designing a high-quality health care system to identify areas where aspects of cultural competence would be central to achieving high quality. It then presents a framework outlining both hypothetical and proven strategies for delivering high-quality, culturally competent care.
The 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, highlights a significant gap between the quality of health care people should receive, and the quality of care they actually receive. But it is important to consider more than just provision of recommended care in determining health care quality. There is growing recognition that—in addition to being based on the best available scientific evidence—health care should also be easy to navigate, safe, accessible, and responsive to patients' needs. Countless studies, culminating in another influential IOM report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002), have found that people of color often receive a lower quality of care than their white counterparts—even when insurance and socioeconomic status, comorbidities, stage of presentation, and other factors are taken into account.
This report identifies aspects of cultural competence that are synergistic with current efforts to develop a system that delivers higher-quality care and discusses strategies by which the quality and cultural competence movements could be linked.
Cultural Competence and Health Care Quality
To understand how cultural competence ties into efforts to address disparities and improve general health care system quality, it is helpful to carefully examine the six IOM principles of quality.
Safety: According to the IOM, patient safety is not solely about addressing general systems issues to prevent the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (such as administering the wrong medication or dosage). It also entails: avoiding misdiagnosis, preventing patients from exposure to unnecessary risks; and ensuring informed consent. Unequal Treatment highlighted the importance of improving provider–patient communication as a method of addressing racial/ethnic disparities in health care. In particular, the report recommended that health care providers be trained in cross-cultural communication and that health care systems support the use of interpreter services for patients with limited English proficiency. Improved communication through such means has the potential to: improve the capacity of health care providers to make accurate diagnoses; prevent patients from exposure to unnecessary risks from diagnostic procedures (particularly where language barriers play a role); enable providers to obtain truly informed consent; and allow patients to participate in clinical decision-making.
Effectiveness. Crossing the Quality Chasm highlights the importance of using evidence-based guidelines to provide high-quality care. It defines "evidence-based practice" as the integration of the best research evidence with clinical expertise and patient values. Two aspects of cultural competence—systemic and clinical—can play a role in improving effectiveness. First, in order to ensure effective care, systems must be in place to detect health disparities by stratifying measures by race/ethnicity. Use of interpreter services as a vehicle for improving communication is also essential. Second, clinical cultural competence, which includes health care providers' ability to ascertain patient preferences and values, is a clear component of effectiveness.
Patient-centeredness. Crossing the Quality Chasm states that compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient are the hallmarks of patient-centeredness. Many would agree that these attitudes and skills are also central to clinical cultural competence.
Timeliness and efficiency. Crossing the Quality Chasm states that a timely system is one that prevents patients from experiencing harmful delays in receipt of necessary services, and that an efficient system is one that avoids quality and administrative waste. Language barriers may contribute to increased length of stay in the hospital or longer wait times in an emergency department. Systemic cultural competence could thus improve the timeliness and efficiency of a system by getting patients the services that are appropriate in an expeditious fashion.
Equity. Crossing the Quality Chasm states that a system is high quality if it provides care that does not vary because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Systemic cultural competence, which entails processes to monitor the quality of care and detect disparities by stratifying measures by race/ethnicity, would lay the foundation for targeted quality improvement activities.
Quality Improvement Approaches
Specific quality improvement approaches, such as disease management (DM) and the chronic care model (CCM), have typically operated in "cookie-cutter" fashion, relying on technology, telephone contacts, and case management. A review of the key principles of CCM and DM identifies areas where cultural competence could be embedded.
- Identify patients who need care: Since both the CCM and DM create registries of patients with specific chronic conditions (e.g., diabetes), a culturally competent approach would ensure that these registries are stratified by race, ethnicity, and language proficiency and thus geared to identify racial/ethnic disparities in health care.
- Provide care by tailoring the methods used to the patient's needs: In CCM and DM programs, physicians, case management nurses, and other members of multidisciplinary care teams seek to communicate with patients outside of the traditional office visit, for example through telephone contact, e-mail, and group visits. A culturally competent approach would establish ways to communicate with patients with limited English proficiency, limited health literacy, alternative health beliefs, and other needs.
- Support physicians and multidisciplinary teams in their clinical decision-making: Once sociocultural barriers to care are identified and interventions to address them are put in place, physicians could be enlisted to help. For example, physicians could be provided with information solicited by other health care team members regarding patients' understanding of their conditions or their fears and concerns about a medication. Thus, physicians' clinical decision-making and care management strategies could be informed by information about patients' sociocultural barriers to care and can engage in culturally competent approaches to address them.
- Support patients in their ability to help manage their own illnesses: To make this process culturally competent, educational information could be provided to patients in the appropriate languages and reading levels. In addition, self-management advice and strategies should take into account key issues related to patients' social context, such as their physical environment and ability to exercise.
- Provide physicians, teams, and physician organizations with feedback on their performance: Stratifying performance feedback by race, ethnicity, culture, and language proficiency would enable health teams to identify issues as they arise, and address them as they emerge in distinct populations.
Quality, Cultural Competence, and Disparities: A Framework
This analysis presents a framework to consider the interplay among cultural competence, quality, and racial/ethnic disparities in health care. It presents hypothetical interventions based on evidence, as well as evidence of strategies that have been found to work. The framework, presented in Table ES-1, explores the root causes of disparities, how cultural competence might address them, and what other approaches outside of cultural competence are needed. Any efforts to address racial/ethnic disparities must be predicated on effective, standardized collection of race/ethnicity data, stratification of those data by race/ethnicity, and commitment to developing interventions to address disparities if and when they are found.
Table ES-1. Health System Level Factors, Care Process Variables, and Patient-Level Variables
|Root Cause of Disparities||Cultural Competence Strategies to Address Them||Other Strategies to Address Them|
|Health system level factors|
|Health system complexity|
(system particularly complex for those with limited English proficiency, low health literacy, mistrust, and little familiarity with the Western model of health care delivery and practice)
Multilingual, low literacy written materials(H)
Culturally competent disease management(E)
Health care navigators(E)
|General disease management(E)|
|Care Process variables|
|Little attention or skill in dealing with patients from diverse sociocultural backgrounds leading to poor communication and clinical uncertainty||Cultural competence education(H)|| |
|Provider stereotyping of patients leading to different recommendations for diagnostic or therapeutic procedures||Curricula on the impact of race/ethnicity on clinical decision-making(H)||Physician reminders (e.g., via electronic medical records)(E)|
Performance review, reporting, and detailing(E)
|Providers caring for patients with limited-English proficiency in the absence of an interpreter||Interpreters(E)|| |
|Difficulty navigating the health care system||Health Care navigators(E)||Patient reminders(E)|
|Mistrust and discomfort voicing concerns or asking questions of the provider||Patient activation programs(H)|| |
|Note: H=Hypotheses, E=Evidence.|
Source: Author's analysis
J. R. Betancourt, Improving Quality and Achieving Equity: The Role of Cultural Competence in Reducing Racial and Ethnic Disparities in Health Care, The Commonwealth Fund, October 2006